Nothing But the Tooth: Make sure you understand the treatment plan

Dr. Richard Greenberg More Content Now

Tuesday

May 7, 2019 at 11:24 AMMay 7, 2019 at 11:24 AM

Q: I was wondering if this was protocol: I went to my dentist because a small filling had fallen out of my molar. After novacaine, the two dentists were talking about my tooth being cracked. My dentist filled my tooth and off I went. A couple of weeks later I went back for a cleaning with a dull ache; it was the tooth that was filled. I mentioned it to her. She filed down the filling and said that should fix it. Six months later, for another cleaning I find out my tooth was infected. They want to send me to get a root canal. I told her my tooth may be cracked and asked if that was that not in her notes? She said we will have to pull it. Now my tooth is gone, I had a bone graft and I can’t afford another tooth. What could I have done if anything to change the outcome? Thank you.L.B.

A: The first thing that was not protocol was that your dentist should explain what had happened to cause the filling to fall out and why, if she knew why. Fillings, if done properly, do not just fall out. Then she should have shown you on a monitor with an intra-oral camera, what the tooth looked like with the filling missing. That is very important as you then can see the size of the filling needed relative to the size of the tooth. Sometimes an ordinary filling is not the right answer. The dentist should have discussed with you the type of restoration needed, the type of material to be used, the pros and cons of the procedure and what you could expect for a lifespan. That should be normal dental office protocol.

I do not know why the dentists were talking about your tooth being cracked without including you in the conversation. Sounds like you just overheard them talking. A crack is no matter of fact observation but is very important and needs to be shown to you, the patient. My question to you is whether you had discomfort on biting pressure with the tooth before and after the filling came out. If there was a crack in the tooth, it will usually cause a significant “jolt” when biting at a certain angle. You did not mention that so I assume you did not notice discomfort on biting.

When you went back for hygiene and said the tooth was sensitive, my dental question to you would have been, “When is there sensitivity and what causes it, hot, cold or chewing?” Also, “did the tooth have to be stimulated to be sensitive? If you left it alone was it noticeable?” It sounds like she did not ask these questions and just felt a bite adjustment was needed and that that would fix the problem. Sometimes that is the right approach but you need to always ask the other questions I noted before doing any treatment, even just filing it down. If done right the first time, why was it being filed down six months later?

After the file-down visit occurred, were you then comfy for the next six months? Were there any signs or symptoms which might have given you an indication of some problem brewing? You do not mention any and I therefore assume none. What was the explanation that your dentist gave you as to why there was an infection? What did she see? This is especially important if you had no symptoms. If she said that you should go for root canal and you had to remind her of the previous crack and then she said that it would have to be extracted, I would immediately start to feel uneasy and start to ask questions. You seemed to have just gone along with her when I would have hoped that you would have shown some resistance. Your intuition should have been giving you warning signs. First, the dentist said all was fine after the bite adjustment was done and then at the next visit says it is infected and does not even have the record note that she, the dentist, felt the tooth was cracked. All that should make you feel what I have tried to emphasize in other columns and that is that the doctor is not always right and you may need a second opinion. Sadly, you did not and the tooth is now gone.

Let us assume that it would have to have been extracted anyway. Why was a bone graft done? That is not routine. To all my readers, for general information, it appears now that every time a dentist does an extraction they recommend a bone graft with the thought that if you decide to do an implant in the future, it would be advantageous. A bone graft costs money, takes very little office time and effort but adds significantly to your cost and the dentist’s income. These grafts are not routinely needed. I am very skeptical as to why now they are so often done. For many years, teeth were extracted and we waited until healing took place (bone regrew naturally) and then put in an implant if that was the treatment decided upon. A bone graft was often not needed. Nature let it heal, forming new bone with no cost to you. Nature is often on our side.

Remember, you do not always have to replace a missing tooth. It is your choice with doctor input. If you decide to replace the tooth, there needs to be a reason and the replacement proposed is not always an implant. There are many other alternatives, some more complicated, some less complicated. Some cost more and some, far less. All this has to be discussed.

I think you now realize that the outcome might have changed with your becoming more active in the decision-making process regarding treatment for your oral health. It is most important for you the patient to advocate for yourself and clearly understand what and when you need treatment from any health professional.Dr. Richard Greenberg practiced dentistry for 45 years after having attended dental school at Columbia University, where he was later an associate clinical professor of restorative dentistry and facilitator of the course of ethics. Do you have a dental question or comment about the column? Email him at dr.richard@nothingbutthetooth.org.